The Patient With An Altered

Mental Status

Ns. Fajri Andi Rahmawan, M.Kep

 Objectives
◼ Upon successful completion of this module, the
ECRN will be able to:

◼ 1. Identify components evaluated in determining a

patient’s mental status and orientation.
◼ 2. Define altered mental status.
◼ 3. Identify the possible causes of altered mental
status.
◼ 4. Identify signs and symptoms of altered mental
status.
◼ 5. Identify elderly considerations related to altered
mental status.
 Objectives cont’d
◼ 6. Identify assessment procedures related to
patients with altered mental status.
◼ 7. Describe how to obtain an accurate Glasgow
Coma Scale assessment.
◼ 8. Describe the procedure to obtain a blood
glucose determinant.
◼ 9. Identify the components of the Cincinnati
Stroke Scale.
◼ 10. Identify Region X field treatment of patients
with altered mental status.
 Objectives cont’d
◼ 11. Identify the indications,
contraindications, complications, and
documentation when using the QuickTrach
airway device.
 Normal Mentation
◼ To identify abnormal mental status, need to
understand what is normal
◼ We all practice a number of means and ways to
identify the mental status
✓ General appearance
✓ Orientation to person, place, and time
✓ AVPU
✓ Alert

✓ Responds to verbal stimuli

✓ Responds to painful stimuli

✓ Unresponsive
 General Appearance
◼ Can gain important information looking at the
“big picture”
◼ Observe hygiene
◼ Observe clothing
◼ Observe overall appearance
◼ Observe verbal and nonverbal behavior
◼ Facial expressions
◼ Tone of voice, volume, quality, speech pattern
◼ Eye contact
◼ Memory intact for recent and long-term events?
◼ Is the patient focused; paying attention?
 Orientation to Person, Place, Time
◼ Can be insulting to a patient to ask pointedly
“what’s your name?” “who’s the president?”
◼ Often helpful to state:
◼ “Since I don’t know your condition very well, I
need to ask some very basic questions.”
◼ Person – patient can state their name
◼ Place – patient can recognize they are at home,
in a store, in an ambulance, at a hospital
◼ Time – patient can tell what year it is and time
of year (by month or season)
 AVPU
◼ A – alert meaning the patient is awake
◼ “A” is not meant to indicate orientation; just level of
awakeness
◼ V – responding to verbal stimuli only
◼ Any response including fluttering of eyelids is a positive
response to calling the patient’s name or asking a command
◼ P – responding to “pain”
◼ Could also indicate responding to tactile stimuli so do not
always need to inflict a painful stimuli
◼ Any response including fluttering of eyelids or any body
twitch is a positive response
◼ U – unresponsive
◼ Patient is flaccid with no responses at all
 Stimulating a Painful Response
◼ Acceptable methods
◼ Pressing on supraorbital ridge (bone below eyebrow)
◼ Trapezium squeeze – twisting muscle where neck and
shoulder meet
◼ Rubbing sternum with knuckles
◼ Pressing on finger nail bed
◼ Unacceptable methods
◼ Any technique that would leave bruising
◼ Discouraged methods
◼ Any stimuli that may cause movement of the c-spine in
a trauma patient by pulling away from the stimuli
 Altered Mental Status
◼ Patient not awake, not alert or not oriented
◼ Patient not aware of their environment
◼ Patient not oriented to person, place, time
◼ Patient confused
◼ Patient unable to demonstrate an understanding of
what is being said

◼ Most important is noting any change over the

course of time in level of consciousness
 Level of Consciousness
◼ One of the first indicators to change when the
level of perfusion is diminishing is level of
consciousness

◼ FYI – The blood pressure is one of the last

indicators to change when the level of
perfusion diminishes
 Possible Cause of Altered Mental
Status
◼ Many lists have been created
◼ Mnemonics have been created to trigger lists
◼ AEIOU-TIPS
◼ SMASHED
◼ EMS should think outside the box and look for
all potential causes
◼ When you find one cause, keep looking in case
there are more than one cause associated with the
altered mental status
 Thinking Outside The Box
How many squares do you see?
 Thinking Outside The Box

30 squares:

◼ 1 large 4 x 4 square
◼ 16 small 1 x 1 squares
◼ 4 – 3 x 3 squares in each corner
◼ 9 – 2 x 2 squares
 Mnemonic - AEIOU-TIPS
◼ A – alcohol
◼ E – endocrine, electrolytes, encephalopathy
◼ I – insulin
◼ O – opiates
◼ U – uremia
◼ T – trauma – head injury, blood loss (shock)
◼ I – intracranial, infection
◼ P – poisoning; psychiatric
◼ S – seizures; syncope
 Mnemonic - SMASHED
◼ S – substrates, sepsis
◼ Hyper/hypoglycemia, thiamine

◼ M- meningitis, mental illness (ie: psychosis)

◼ A – alcohol (intoxication/withdrawal)
◼ S – seizure, stimulants
◼ H- hyper/hypothyroidism, hyper/hypothermia,
hypotension, hypoxia, hypercarbia
◼ E – electrolyte imbalance, encephalopathy
◼ D- drugs of any sort
 A - Alcohol
◼ Includes beer, wine, and spirits
◼ Alcohol is a psychoactive drug with depressant
effects
◼ Decreases attention and slows reaction speed
◼ Short term effects: intoxication, dehydration, alcohol
poisoning
◼ Long term effects: changes to metabolism in the liver
and brain; possible addiction
◼ Binge drinking
◼ Men- 5 or more drinks in a row

◼ Women – 4 or more drinks in a row

 A- Alcohol
◼ Evaluate
◼ Clarity of speech
◼ Ability to comprehend the conversation
◼ Gait
◼ Not all persons drinking alcohol have altered mental
states
◼ EMS to contact Medical Control if the patient with
alcohol “on board” wants to sign a release
◼ ECRN needs to involve MD in dialogue and
decision making
 E - Endocrine
◼ Endocrine system is an informational system
much like the nervous system
◼ Chemical messengers, hormones, travel mainly
via blood vessels to trigger responses
◼ Common conditions involving the endocrine
system
◼ Diabetes mellitus
◼ Thyroid disease
◼ Obesity
 E - Electrolytes
◼ Electrically conductive medium
◼ Principally: sodium, potassium, calcium,
magnesium, chloride
◼ Activates muscles and neurons
◼ Homeostasis of electrolytes regulated by hormones
◼ Generally kidneys flush out excess levels of
electrolytes
◼ Electrolyte disturbance (ie: dehydration or
overhydration) may lead to cardiac and neurological
complications (ie: medical emergencies)
◼ Dehydration: exercise, diaphoresis, diarrhea,
vomiting, intoxication, starvation
 E- Encephalopathy
◼ A syndrome of brain dysfunction
◼ Brain function and/or structure is altered
◼ Causes
◼ Brain infection, tumor, increased intracranial
pressure, exposure to toxins, radiation, tumor, poor
nutrition, hypoxia, decreased blood flow to the brain
◼ Hallmark – altered mental status
◼ Common signs and symptoms include loss of
cognitive function and subtle personality
changes
◼ More signs and symptoms listed in the notes section
 I - Insulin
◼ Diabetes mellitus
◼ The brain is very dependant on a set glucose
level to function
◼ If the glucose level falls, the brain cannot
function normally
◼ Rapid change in behavior, level of
consciousness when the blood sugar level
drops
◼ All persons with altered level of consciousness
need to have their blood sugar level checked
 O - Opiates
◼ Used for pleasure and pain relief
◼ Depresses body functions and reactions
◼ Taken in pill form, smoked, injected
◼ Single dose effect can last 3 – 6 hours
◼ Detection time lasts usually up to 2 days
◼ High physical and psychological dependence
◼ Develop physical symptoms, behavioral
symptoms, health effects, increased pain
tolerance
 Examples of Opiates
◼ Codeine ◼ Lortab
◼ Darvocet ◼ Methadone

◼ Demerol ◼ Morphine

◼ Dilaudid ◼ Percocet

◼ Fentanyl ◼ Percodan

◼ Heroin ◼ Oxycodone

◼ Hydrocodone ◼ Oxycontin

◼ Lorcet ◼ Ultram

◼ Vicodin
 Signs and Symptoms - Opiates
◼ Constricted pupils ◼ Depressed pulse rate
◼ Sweating ◼ Drowsiness
◼ Nausea/vomiting/diarrhea ◼ Fatigue
◼ Needle marks ◼ Mood swings
◼ Loss of appetite ◼ Impaired coordination
◼ Slurred speech ◼ Depression
◼ Slowed reflexes ◼ Apathy
◼ Depressed breathing ◼ Stupor
◼ Euphoria
 U - Uremia
◼ Urea and waste products not eliminated from
the blood
◼ Accompanies kidney failure/renal failure
◼ Usually diagnosed when kidney function
< 50% of normal
◼ Early symptoms: anorexia and lethargy
◼ Late symptoms: decreased mental acuity and
coma
 Causes of Uremia (besides kidney
failure)
◼ Increased production of urea in the liver
◼ High protein diet; GI bleed; drugs; increased
protein breakdown (surgery, infection, trauma,
cancer)
◼ Decreased elimination of urea
◼ Decreased blood flow through the kidneys (ie:
hypotension); urinary outflow obstruction
◼ Dehydration
◼ Chronic kidney infections (chronic
pyelonephritis)
 T - Trauma
◼ Head injury
◼ Epidural bleed

◼ Rapid bleeding with unresponsiveness

often following a lucid interval
◼ Subdural bleed

◼ Slow bleeding with subtle changes

◼ Intracerebral bleed

◼ Ruptured blood vessel releases blood into

brain tissue with resulting tissue edema
◼ Blood loss ➔ shock
 I - Intracranial

◼ Tumor
◼ Symptoms/neurological deficits often point to the
area of brain affected
◼ Right sided brain insult affects left sided body

function
◼ Left sided brain insult affects right sided body
function
 Intracranial cont’d
◼ Head injury
◼ Pupillary changes reflect same side of brain insult

◼ Right pupillary change reflects right sided brain

insult
◼ Left pupillary change reflects left sided brain
insult
◼ Consider acute vs chronic condition

◼ Chronic conditions:

◼ Elderly with frequent falls

◼ Chronic alcoholism with frequent falls

 I - Infection
◼ Meningitis
◼ Bacterial is highly contagious
◼ Mask the patient and all medical personnel caring for
patient
◼ Urinary tract infection (UTI)
◼ Elderly often do not present with high fevers
◼ Sepsis
◼ Newborns/very young infants will be very ill
◼ Encephalitis
◼ Pneumonia – viral and bacterial
◼ Liver abscess
 P - Poisoning
◼ Drug overdose
◼ Intentional

◼ Assume you are not getting the full story

◼ Mixing any meds with alcohol increases the risk

of worsening conditions
◼ Accidental

◼ Assume young children will not be truthful (fear

of being punished)
◼ EMS to bring in all containers
 P - Psychiatric
◼ Schizophrenia
◼ Common mental health problem
◼ Hallmark – significant change in behavior and loss
of contact with reality
◼ Hallucinations, delusions, depression
◼ Bipolar
◼ Not particularly common mental health problem
◼ One or more manic episodes with or without
subsequent or alternating periods of depression
 S - Seizure
◼ Epilepsy
◼ Head injury
◼ Hypoglycemia
◼ Hypertensive crisis
◼ Rapid increase in diastolic B/P >130mmHg
◼ Hypertensive disorder of pregnancy
◼ Formerly referred to as toxemia
 S- Syncope
◼ Brief loss of consciousness with spontaneous
recovery
◼ “Fainting”
◼ Typically a very short episode resolved when the
patient lies flat (as in when they pass out)
◼ Often warning signs &/or symptoms
◼ Lightheadedness Vision changes
◼ Dizziness Sudden pallor
◼ Nausea Sweating
◼ Weakness
 Causes of Syncope
◼ Hypovolemia – fluid &/or blood loss
◼ Metabolic – alteration in brain chemistry
◼ Hypoglycemia
◼ Inner/ middle ear problem

◼ Environmental
◼ Room temperature, carbon monoxide

◼ Screen patient with RAD 57 tool if carbon

monoxide suspected
◼ Toxicological – excessive alcohol
◼ Cardiovascular - dysrhythmias
 Elderly Considerations
◼ Contributing factors to confusion
◼ Stress
◼ Fear of removal from their home
◼ Talking with strangers (ie: EMS, hospital staff)
◼ Answering questions they do not know the
answers to
 Elderly Considerations
◼ Altered mental status possibly due to:
◼ Medical insult or traumatic head injury
◼ Heart rhythm disturbance; AMI
◼ Dementia
◼ Infection
◼ Related to prescription medications
◼ Decreased blood volume – shock
◼ Respiratory disorders and/or hypoxia
◼ Hypo/hyperthermia
◼ Decreased blood sugar level
 Distinguishing Dementia From
Delirium
◼ Dementia ◼ Delirium
◼ Chronic, slow ◼ Rapid in onset (hours to days),
progression fluctuating course
◼ Irreversible disorder ◼ May be reversed esp if treated
early
◼ Impaired memory ◼ Greatly impairs attention

◼ Global cognitive deficits ◼ Focal cognitive deficits

◼ Most commonly caused ◼ Most commonly caused by

by Alzheimer’s systemic disease, drug toxicity,

or metabolic changes
◼ Does not require ◼ Requires immediate treatment
immediate treatment
 Dementia
◼ Causes of this progressive disorientation
◼ Small strokes
◼ Atherosclerosis
◼ Age related neurological changes
◼ Neurological changes
◼ Certain hereditary diseases (ie: Huntington’s)
◼ Alzheimer’s disease
 Delirium
◼ Disorganized thinking with reduced ability to
maintain attention and to shift attention
◼ Synonyms:
✓ Acute confusional state
✓ Acute cognitive impairment
✓ Acute encephalopathy
✓ Acute altered mental status
 Patient Assessment
◼ ABC’s
◼ Is ventilation/breathing adequate?

◼ Does supplemental oxygen need to be given?

◼ Room air contains 21 % O2

◼ Nasal cannula delivers 24% - 44% O2 (2 – 6

L/min)
◼ Non-rebreather can deliver up to 100% O2 (12-15
L/min)
◼ Does the C-spine need to be controlled?

◼ Can the patient protect their own airway?

 Patient Assessment
◼ Adequacy of circulation
◼ What is the blood pressure?
◼ Does the blood pressure equate with the patient
assessment?
◼ Is there a peripheral pulse?
◼ What is the peripheral pulse rate and quality?
◼ Do you need to gain IV access?
◼ Is IV access necessary?
◼ Is IV access needed as a precaution?
 Patient Assessment
◼ Cardiac monitor
◼ Is there a dysrhythmia present?

◼ What is the blood sugar level?

◼ Does the patient require isolation for potential
infectious disease?
◼ History
◼ From the patient, caregiver, bystander

◼ History of present illness

◼ Pertinent past medical history
 Patient Assessment
◼ Allergies
◼ Current medications
◼ Use of drugs or other substances
◼ Physical exam
◼ Vital signs – B/P – P – R – SpO2

◼ Hands-on assessment head to toe

◼ Skin exam

◼ Rashes? Evidence of infection?

 Patient Assessment - Neurological

◼ Evaluate appearance, behavior, attitude

◼ Thought disorders – logical and realistic?
◼ False beliefs/delusions?
◼ Suicidal/homicidal thoughts?
◼ Perception disorders?
◼ Hallucinations present?
◼ Mood and affect
◼ Insight and judgement – can patient understand
circumstances and identify surroundings?
◼ Sensorium and intelligence – normal level of
consciousness? Impaired cognition/intellectual
functioning?
 Neurological Assessment cont’d
◼ Level of consciousness
◼ AVPU
◼ Pupillary response
◼ Ability to identify person, place, time
◼ Glasgow coma scale
◼ Scores 3 – 15
◼ More important than any one score is the trend the
score is making
 Glasgow Coma Scale
◼ Evaluates wakefulness and awareness
◼ Wakefulness
◼ The state of being aware of the environment
◼ Awareness
◼ A demonstrated understanding of what is being
said
 GCS Tips
◼ Always give the patient the best score possible
◼ If the patient can move the right extremity and not
the left, score for the movement of the right
extremity
◼ Deteriorations will be noted faster as the score
drops by awarding the highest points possible
◼ Pediatric component
◼ Used for the young patient who is not yet verbal
due to age
 Glasgow Coma Scale
EYE VERBAL
MOTOR RESPONSE
◼
OPENING RESPONSE
4--Spontaneous 5--Oriented 6--Obeys
3—Verbal 4--Confused/
5—Localizes/purposeful
stimuli disoriented
3--Inappropriate
2--Pain 4--Withdraws
words
2--Incomprehensible
1--None 3--Abnormal flexion
sounds
1--None 2--Extensor posturing

1--None
 GCS Score
◼ GCS 13 – 15
◼ Mild brain injury
◼ GCS 9 – 12
◼ Moderate brain injury
◼ GCS <8
◼ Severe brain injury
◼ Most patients with this score are in coma
◼ Evaluate for the need to assist in protecting the
patient’s airway
 Evaluating Eye Opening
◼ Best response is obtained, if at all possible,
before physical contact is made with patient
◼ This is not always possible when the C-spine needs
to be controlled as c-spine control occurs
immediately before other interaction with patient
◼ Patient gets credit if eyelids open even for a
brief moment or just flicker
◼ Always consider need to control the C-spine
over the verbal response of the GCS
 Evaluating Verbal Response
◼ 5 – uses appropriate words/conversation
◼ 4 – speaks but is confused and disoriented
◼ 3 – speaking and you can understand the words
spoken but the words do not contribute to the
current conversation
◼ 2 – making sounds like grunts and moans; no
intelligible words
◼ 1 – no response; no speech; no noise
 Modifying GCS for Pediatrics
◼ Adult GCS must be modified to match the
developmental age of the young nonverbal child
◼ Best eye opening remains unchanged
◼ Best verbal response for non-verbal patient
◼ 5 – Smiles, coos, follows objects
◼ 4 – Irritable cry but is consolable
◼ 3 – Inappropriate crying; cries to pain
◼ 2 – Inconsolable, agitated; moans or groans to pain
◼ 1 – No response
 Evaluating Motor Response
◼ 6 – Obeys commands
◼ 5 – Localizes/Purposeful movement
◼ Hits at you, grabs at your hands, pulling equipment
off, pushing you away
◼ 4 – Withdraws from pain (unable to localize)
◼ 3 – Flexing with internal rotation and
adduction of shoulders and flexion of elbows
◼ 2 – Extension with elbows straightened and
possible internal shoulder and wrist rotation
 Pediatric GCS Motor Response
◼ Best motor response for non-verbal patient
◼ 6 – obeys commands
◼ May be difficult to determine if child understands

◼ 5 – localizes pain by withdrawing to touch stimuli

◼ 4 – withdraws to pain (more stimuli than touch)
◼ 3 – same – abnormal flexion
◼ 2 – same – abnormal extension
◼ 1 – no motor response; patient flaccid
 Blood Glucose Level
◼ To be obtained in the field when:
✓ Patient is known diabetic with diabetic related
problem
✓ Patient has an altered level of consciousness for
unknown reasons
✓ Patient is unresponsive (includes post-ictal patients)

◼ Consider the patient to have more than one problem at a

time
◼ Make sure a 2nd or 3rd issue is not present once you
find the first issue (ie: hypoglycemia)
◼ Be aware: Peds patients can drop their blood sugar level
fast
 Blood Glucose Monitor
◼ Machines calibrated for capillary specimen
◼ Keep the site hanging dependently
◼ Can use side of finger tips or the forearm

◼ Once the site is wiped with an alcohol prep pad, let

the site air dry before obtaining a sample
◼ Use a lancet to obtain a blood sample from the finger
or forearm
◼ Patient should not sign a release until EMS can
document a blood sugar level >60 in the field
 Stroke Care
◼ Rapid detection of signs and symptoms with
rapid diagnosis is essential
◼ Need to avoid delays
◼ 3 hour time limit to administer a fibrinolytic
from time of first onset of signs and
symptoms
◼ Increase risk of cerebral bleeding beyond
a 3 hour time frame
◼ Most important question to ask:
◼ What time did symptoms begin?
 Cincinnati Stroke Scale
◼ Quick and simple evaluation tool
◼ Documentation
◼ Facial droop
◼ Right/left facial droop or no droop

◼ Arm drift
◼ Right/left arm drift or no drift

◼ Speech
◼ Clear or not clear
 Facial Drooping

◼ Ask the patient to smile real big and show you

their teeth
◼ Best way to see if a droop is present
 Arm Drift

◼ Demonstrate first and then have patient hold

their hands out in front, palms up, for 10
seconds
 Clarity of Speech
◼ Most likely you’ll know by now if there is a
speech problem
◼ Can have the patient repeat after you any
words or a sentence you give them
◼ “You can’t teach an old dog new tricks”
 7 D’S Of Stroke Care
◼ Detection – of signs and symptoms
◼ Dispatch – patient to call 118/119
◼ Delivery – by EMS to the appropriate facility
◼ Door – emergent triage in the ED
◼ Data – appropriate tests
◼ Decision – to administer a fibrinolytic or not after
diagnostic tests and assessment completed
◼ Drug – must administer the fibrinolytic within 3
hours of onset of symptoms
Quick Fixes of Altered Mental Status

◼ Hypoglycemia – Dextrose
◼ Hypoxia – oxygen
◼ Pinpoint pupils – Narcan
◼ Seizures – Valium
◼ Dextrose if seizure due to hypoglycemia

◼ Cold – warm the patient up

 Documentation Tips
◼ All patients require a blood glucose level for altered
mental status
◼ Documentation should reflect serial monitoring of the
patient’s condition looking for changes
◼ GCS
◼ AVPU
◼ If restraints are used, document objectively and in
detail the behavior that led to the need for restraints
◼ Document distal circulation of any restrained
extremity
◼ Patients with altered mental status cannot sign a
release in the field
 Securing the Airway - QuickTrach
◼ Indications
◼ Patient requires emergency assisted ventilation
when all other conventional methods have failed
◼ Contraindications
◼ Tracheal transection

◼ Other less invasive maneuver allows ventilation

◼ >77# (35kg) – use 4.0mm ID device
◼ 22# – 77# (10 -35kg) use 2.0 mm ID
◼ <22# (10kg) – use needle cricothyrotomy
QuickTrach Device
Connecting
tube
Syringe
Flanges to
attach ties
Stopper that is
removed
before final
insertion
 QuickTrach Procedure
◼ Patient positioned supine; neck hyperextended if
no trauma)
◼ Cricothyroid membrane located and site cleansed
Palpate the soft indentation between
the thyroid and cricothyroid cartilages
◼ Larynx secured laterally between
the thumb and forefinger
◼ Cricothyroid membrane punctured
at a 900 angle
Cricothyroid Membrane

Target
area
 QuickTrach cont’d
◼ Entry into the trachea confirmed by aspirating air thru
the syringe
◼ If air is present, the needle is in the trachea

◼ Now angle changed to 600 with the tip pointing

towards the feet and device advanced forward into the
trachea to the level of the stopper
◼ Stopper to be snug against the skin

◼ Stopper reduces risk of inserting the needle too

deeply
◼ Stopper removed
 QuickTrach cont’d
◼ Needle and syringe held firmly, only the
plastic cannula is slid into the trachea
◼ Advancement stopped when the flange rests
snug against the neck
◼ Needle and syringe carefully removed
◼ Connecting tube attached to the cannula
◼ Can be preattached to BVM and then attached to
cannula when needle and syringe are removed
◼ BVM attached to the connecting tube
◼ Patient can be bagged

◼ Cannula secured with the neck tape ties

provided
 QuickTrach Complications
◼ Puncture through of the trachea
◼ During bagging attempts surrounding tissue will
expand due to leakage of air
◼ Inadvertent puncture of a blood vessel
◼ Formation of a hematoma under the skin and
surrounding the airway
◼ External bleeding
◼ Inability to ventilate the patient
◼ There may be an obstruction at a more distal site
 QuickTrach Documentation
◼ Reason(s) an alternate airway devise was
necessary
◼ Size of airway placed
◼ 4.0 mm for persons over 77#
◼ 2.0 mm for persons 22# - 77#
◼ Confirmation of airway placement
◼ Bilateral breath sounds
◼ Bilateral chest wall rise and fall
Melker Airway Device
Arndt Airway Device
 Bibliography
◼ Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles and Practices 3rd Edition. Prentice Hall.
2009
◼ Limmer, D. O’Keefe, M. Emergency Care. 10th
Edition. Prentice Hall. 2005.
◼ Region X SOP’s March 2007. Amended January 1,
2008.
◼ En.wikipedia.org/wiki/Endocrine_system
◼ En.wikipedia.org/wiki/Electrolyte_system
◼ En.wikipedia.org/wiki/Encephalopathy_system
◼ En.wikipedia.org/wiki/Opiate_system
◼ En.wikipedia.org/wiki/Uremia_system
 Bibliography cont’d
◼ www.chems.alaska.gov/EMS/documents/GCS_Activity_
2003.pdf
◼ www.doi.gov/nbc/eps/signsymptoms.html
◼ www.en.wikibooks.org.wiki/Emergency_Medicine/altered
_mental_status
◼ www.nursingtimes.net
◼ www.opiates.com/opiates
◼ staff.washington.edu/momus/PB/comachan.htm
◼ www.ucsfcme.com/2008/slides/MDM08Q05/01-
sporer.pdf
◼ www.uic.edu/com/ferne/slides/Delerium.pps